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Introduction
Worksheet Example
Worksheet
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Module Summary
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Introduction
In Module 2, we identified that people with BDD will often engage in repeated checking and reassurance
seeking behaviours. Generally this is done in an effort to ease concerns you have about your appearance.
However, these behaviours can actually fuel the problem, keeping you preoccupied with your appearance,
magnifying your negative body image, increasing your distress, and stopping you from learning the necessary
skill of tolerating your physical imperfections. In this Module, we will revisit the different ways people check
and seek reassurance about their appearance, discuss helpful and unhelpful levels of checking, and explore
strategies to reduce or eliminate these behaviours.
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The goal of this module is therefore not to move you from one extreme to the other, by asking you to
eliminate all checking and reassurance seeking behaviours. The goal is to be able to develop more helpful
levels of these behaviours and to decrease the negative consequences often associated with high levels of
checking and reassurance seeking.
Note: In the next module, we will address avoidance behaviours that can occur at the other end of this continuum
(e.g., for people who never check or seek reassurance e.g., avoid mirrors, never look at photographs of self).
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Did you find this difficult??? This is just another example of how our brains are not unbiased when it comes
to processing what they can see right in front of them. What we see gets influenced by what our brains
already know or think they know. Just as identifying the colour is being influenced by our brains knowledge
of the word, when our brain processes our appearance in the mirror, it is not impartially seeing the
reflection in front of it, but is very much influenced by what we think we already know about that reflection
(i.e., I have a big nose). Our brains can be very tricky in this way, often not seeing what is really there in
an objective way, but instead seeing what we think we already know.
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If you are not sure whether your behaviour is one that other people engage in, you could ask a trusted
friend whether they do the behaviour, and if so how much. You could also ask yourself whether you would
feel worried or embarrassed if someone saw you engaged in your behaviour. This could give you some
clues as to what you and others might think about how helpful or common the behaviour is. Also, you
could simply start by decreasing your behaviour and then later make a decision about eliminating it.
Step 2 - Generate and evaluate a new behavioural goal
Based on your decision to decrease, postpone or eliminate your behaviour, you will need to:
generate a new behavioural goal, and
identify what specifically you will do to work towards this goal
In some circumstances, the new goal and specific behaviours attached can be easily identified and attempted
straight off. For example, imagine that you had been using callipers to ascertain how loose the skin on your
stomach is. Your new behavioural goal might be to eliminate using the callipers, as this behaviour is
currently maintaining your negative body image. The specific behaviour attached to this goal might then be
I will throw away my callipers and ride out the initial worry I have about not being able to measure.
However, sometimes reducing or eliminating particular behaviours may be something that you need to do
more gradually. For example, if you had been spending several hours closely checking the wrinkles around
your eyes in the mirror each day, and your goal was to only use my mirror for ten minutes in the morning
for shaving, there is a chance that this would be too difficult to do straight away. Instead you could break
this goal down into smaller steps, gradually working towards the recommended level of checking.
To make gradual reductions in a particular behaviour we recommend that you use a Stepladder
to help you: 1) identify your overall goal, and 2) identify the gradual steps needed to work
towards your overall goal. Each step on the stepladder can be given a Distress rating between
0 and 100, where 0 = this step is not distressing at all, and 100 = this step is highly distressing.
Your stepladder might have fewer or more in between steps than the example given below,
but the idea is to gradually build up to your overall goal in an achievable manner.
For example:
GOAL: only use my mirror for ten minutes in the morning for shaving
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2
3
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STEP
Place a stopwatch next to the mirror. Allow 60 minutes total
mirror time each day , checking as usual
Allow 50 minutes total mirror time each day, maintain 30cms
between my face and the mirror
Allow 40 minutes total mirror time each day, maintain 40cms
between my face and the mirror
Allow 40 minutes total mirror time each day, twenty minutes in
the morning and twenty minutes at night, maintain 40cms
between my face and the mirror
Allow 30 minutes of mirror time in the morning only, maintain
40cms between my face and the mirror
Allow 20 minutes of mirror time in the morning only, maintain
40cms between my face and the mirror, spend half of time
engaged in shaving and half in checking
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DISTRESS (0-100)
95
DISTRESS
30
45
50
55
60
70
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DISTRESS (0-100)
STEP
DISTRESS
Once you have identified your new behavioural goal and what you will specifically do to work towards this
goal, you will need to ask yourself:
What is the goal of this new behaviour?
Are there any advantages to doing this behaviour as I have planned?
Are there any disadvantages to doing this new behaviour as I have planned?
At this point, how much sense does it make to try out this new behaviour?
By now, you should have a fairly good idea about whether you have developed a helpful new behaviour and
hopefully the scales are tipped towards you wanting to have a go at this new behaviour. However, that
does not necessarily mean that it will be easy to do it!
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Remember that if you check or seek reassurance, it may relieve some worry or uncertainty in the
short term, but in the long term it can keep it going (i.e., the Reassurance Cycle)
View this as good practice in learning to tolerate and accept some uncertainty about how you look
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Are there any disadvantages to doing this behaviour the way I currently
am? Does this behaviour really achieve my goal?
At this point, how much sense does it make to keep going with this behaviour? How much sense does it make to
do it as frequently or for as long as I do? Do the advantages of this behaviour outweigh the disadvantages?
Daily checking makes it hard to tell if anything has really changed and I dont actually catch
anything early because I always think something is wrong. Using the magnifying mirror also makes me
feel terrible.
What is the goal of this new behaviour? Are there any advantages to
doing this behaviour as I have planned?
At this point, how much sense does it make to try out this new behaviour?
I can see there are plenty of reasons to try it out and my boss will be pleased if I am on time for work
How will I manage any distress I experience? What will I say to myself? What will I do?
I will remind myself that I am still going to look at myself in the mirror while applying my make-up. If
there is something that would be obvious to others, I will probably see it then.
I will also use my meditation and postponement exercises to deal with any judgmental thoughts or
worries that arise.
What did I find out about myself? What did I find out about my original and new behaviours?
In the first week I leant in to the mirror a couple of times without realising what I was doing. I guess it
was quite a habit. It was hard at first, but I know now I can ride out the anxiety of not checking.
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No
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Are there any disadvantages to doing this behaviour the way I currently
am? Does this behaviour really achieve my goal?
At this point, how much sense does it make to keep going with this behaviour? How much sense does it make to
do it as frequently or for as long as I do? Do the advantages of this behaviour outweigh the disadvantages?
What is the goal of this new behaviour? Are there any advantages to
doing this behaviour as I have planned?
At this point, how much sense does it make to try out this new behaviour?
How will I manage any distress I experience? What will I say to myself? What will I do?
What did I find out about myself? What did I find out about my original and new behaviours?
No
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Let any mirror use be for a specific and appropriate purpose (e.g., make-up application, shaving,
assessing if your overall outfit matches, seeing if you have food in your teeth, etc). No lengthy
periods in front of the mirror, instead use the mirror for the purpose intended and then walk
away.
Use mirrors at an appropriate distance, rather than up close. Try to be as far away as is
reasonable given the purpose you are using it for.
Try to view your whole face or whole body in a non-judgemental way, as if you were looking at
someone else. Try not to zoom in on specific areas of concern with a critical eye.
Dont check your appearance in other reflective surfaces that can be misleading (e.g., windows,
the toaster, etc).
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Most of us will engage in checking and reassurance seeking behaviours with regards to our appearance.
We do this to reduce any questions or worries we have about how we look, to increase our sense of
control and certainty about our appearance, and to reassure ourselves that we look okay or that the
problem is real.
In the short term, checking and reassurance seeking may provide a sense of relief. However, in the long
term, those same doubts and concerns can continue to pop back into your mind, and the need to
check and seek reassurance will therefore continue in a vicious Reassurance Cycle.
Checking and reassurance seeking behaviours fall on a continuum, where too much or too little can be
unhelpful to you.
Checking behaviours may contribute to the development of an unreliable body image, or maintain an
unfair or even unachievable standard for you.
One way to overcome excessive levels of checking and reassurance seeking is to evaluate and test out
new behaviours that involve reducing, postponing or eliminating the current checking and reassurance
seeking.
It is normal to feel some distress while trying out new behaviours and decreasing your checking and
reassurance seeking. If you are finding things tough, use a Stepladder to break down your new
behaviour goal in to smaller and more manageable steps.
Coming up next
In the next module, you will learn to
challenge negative predictions, and to
reduce any avoidance or safety
behaviours you are engaging in.
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BACKGROUND
The concepts and strategies in these modules have been developed from evidence based psychological
practice, primarily Cognitive-Behaviour Therapy (CBT). CBT for Body Dysmorphic Disorder (BDD) is
based on the approach that BDD is a result of problematic cognitions (thoughts) and behaviours.
REFERENCES
These are some of the professional references used to create the modules in this information package.
Cash, T. (1997). The body image workbook. Oakland: New Harbinger Publications.
Feusner, J., Neziroglu, F., Wilhelm, S., Mancusi, L., & Bohon, C. (2010). What causes BDD: Research
Findings and a Proposed Model. Psychiatric Annals, 40, 349-355.
Knoesen, N. & Castle, D. (2009). Treatment intervention for Body Dysmorphic Disorder. In S.J. Paxton &
P. Hay (Eds.). Interventions for body image and eating disorders. (pp. 284-309). Melbourne: IP
Communications.
Phillips, K. (1996). The broken mirror. Understanding and treating Body Dysmorphic Disorder. New York:
Oxford.
Ross, J. & Gowers, S. (2011). Body Dysmorphic Disorder. Advances in Psychiatric Treatment, 17, 142-149.
Thomson, J.K. (1990). Body image disturbance: assessment and treatment. New York: Pergamon Press.
Veale, D. (2010). Cognitive Behavioural Therapy for Body Dysmorphic Disorder. Psychiatric Annals, 40, 333340.
Veale, D., Willson, R., & Clarke, A. (2009). Overcoming body image problems including Body Dysmorphic
Disorder. London: Robinson.
Veale, D. & Neziroglu, F. (2010). Body Dysmorphic Disorder: A treatment manual. UK: Wiley-Blackwell.
Wilhelm, S., Phillips, K., Fama, J., Greenberg, J., & Steketee, G. (2011). Modular Cognitive-Behavioral
Therapy for Body Dysmorphic Disorder. Behavior Therapy, 42, 624-633.
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